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This is the most important
health report form for you from the viewpoints of traditional Chinese medicine. Please read carefully and tick off the items
correctly, so that our professional doctors could diagnose
accurately and offer effective treatment for you.
The reason why you have to
fill out this form seriously is that TCM is totally different than
western medicine, and it emphasizes every exact individual symptom very
much. Even for the same disease, there are many different reasons to
cause it from person to person. Therefore the treatment is also
different from person to person. Thanks for your understanding and
cooperation.
Your
email:
Name:
Gender: male or
female
Marriage state: married or unmarried
Having a child or children: already or not
yet
Age:
years
Country:
State:
Address:
Postal
(zip) code:
Telephone:
Height:
meters
Weight:
kilograms
Disease
history: how many months or years
Your Current Major Complaint
impotence
premature ejaculation
prostatitis
infertility
UU or chlamydia urinary inflammation
viral
herpes
urinary inflammation caused by gonorrhea
other sexually transmitted diseases
inflammation of the
glans
spermatocystitis
epididymitis
enlarged prostate
hidden
testicle
Your
symptoms related to your male problem
premature
ejaculation, only a few seconds
premature ejaculation, only one to two minutes
premature ejaculation, only two to five minutes
premature ejaculation, only five to ten minutes
reduced
sexual ability
tardy
erection
weak erection
inability to penetrate into the vagina
seminal emission in
the daytime
seminal emission
at night
no desire for sex
frequents masturbation about one to two years history
frequent masturbation about two to four years
frequent masturbation more than four years
one testicle
pains
two
testicles pains
hard mass and pressing pains at the lower part of the epididymis
swollen scrotum
cold and damp
scrotum
itching scrotum
damp and hot
scrotum
strong smell of
the private parts
edema of the
scrotum
pains at perineum
burning
pains in the urethra
needling pains in the urethra
red and
swollen glans
white and dreg-like materials in the foreskin
red small pots can be found on the glans
small blisters and ulcerations on the glans
viral warts on the penis
turbid
urine
sticky excretion at the opening of the urethra when defecating stool
forcefully
sticky excretion at the opening of the urethra when getting up in the morning
dropping sense of
the anus
varicocele
lumbago
pains at the lower
abdomen
hyperactivity
of the sex
clear and
scanty semen
yellow
tainted semen
bloody semen
inability to make female pregnant three years after marriage
shorter than ten centimeter when erecting
pains at the groin area
Other
Symptoms About You:
headache
great
loss of hair
slight
loss of hair
hair
loss with oily scalp
blurred
vision
blood-shot
eyes
dizziness
tinnitus
with noise of chirping of a cicada
reduced
hearing ability
sudden
hearing loss
blockade
sense in the ear orifice
flushed
cheeks only at the zygomatic regions
pale
complexion
swollen
and painful nose
runny
nose
thin
and white nasal discharge
thick and yellowish nasal discharge
blockaded
sense in the nose
a
bitter taste in the mouth
sour
taste in the mouth
dry lips
slightly
reddish
tongue body
slightly pale
tongue body
deep-red
tongue body
purplish
tongue body
fissured
tongue body
tooth-marks
on the edges of the tongue
I
brush the tongue coating daily
thin
and white tongue coating
thick
and white tongue coating
thin
and yellow tongue coating
thick
and yellowish tongue coating
stiff
neck
painful
neck
itching
throat
dry
throat
swollen
and painful throat
frequent
throat inflammation
cough
due to itching throat
dry
cough with little phlegm
spit
thin and white phlegm
spit
thick and yellowish phlegm
chest
oppression
shortness
of breath
slight
palpitations
severe
palpitations
stabbing
pains in the heart
distention
and discomfort of the right rib-side
having slight heart and blood pressure problem
having severe heart and blood pressure problem
stomach
pains
stomach
distention
burning
stomachache
cold
stomachache
shrinking
sense of the stomach
stomachache
likes warmth or warm drinks
stomachache
likes cold drinks
stomachache
likes pressure on it
wish
to vomit
dropping
sense of the stomach
belch
with sour taste in the mouth
lower
abdomen pains
lower
abdomen distention
hernia
painful back
with inability or difficulty to stretch or bend the back
aching
pains of the shoulders and back
lumbago
(painful loins) involving the lower limbs
stiff
and painful loins due to falling or sprain or hard physical work
dull
pains of the loins
cold
sense on the back
Thanks so much for your
patience that you are still working carefully on this form.
stiff
four limbs
general
body pains
muscle
spasm of the body
tight or spasmodic tendons of the general body
running
pains of the body joints
heavy
sense wrapping the body
swollen
and painful joints of the arms
swollen
and painful joints of the legs
edema
of the lower limbs
edema
of the general body
numbness
of the four limbs
aversion
to cold and cold limbs
hot
sense in the soles and palms in the afternoon or night often
day
time sweat
sweat
at night
insomnia
dreaminess
frequent
waking up during sleep
thirst
and like drinks
like
cold drinks
like
hot drinks
reduced
appetite
easy
hunger and excessive food-intake
hunger
without desire to eat
eat
much cold foods
eat
much fast foods
irregular
food intake
frequent
daytime urination
urgency
in urination
white
urine
yellowish
urine
dark yellow
urine
painful
urination
frequent
night urination
dribbling urine after urination
constipation
diarrhea
with burning sense at the anus
diarrhea
with clear undigested foods
diarrhea
worsened by emotional frustration or distress
diarrhea
every 5 O'clock (AM) with abdominal pains
powerful pulse
weak
pulse
thin
pulse body like a thread
deep
pulse
string-like
pulse (touching the wrist pulse like touching a tight string of a musical
instrument)
abnormal
rhythm of pulse
Living
Environment:
always
a cold and windy living environment
damp
living environment
dry
living environment
Temperament
and Emotions:
optimistic, open-minded and happy
pessimistic
melancholic
always
worrisome
nervous often
overthinking
often
lone
and close-minded
easy
to be angry always
depressed
often
irritability
often
Spirit and work:
fatigued
very
much fatigued
stressful
work
very much stressful work
What about
other information related to your Major Complaints? Do you have the problems of
the heart and blood pressure? Slight or serious?
What
kind of foods do you like? What
are your daily foods? Do you smoke? What are your private hobby? Do
your family members suffer the similar health problems?
If you have
some clinical laboratory examinations, please offer the
results. Also you could fax the documents of your laboratory check to our 86 745
2390037. Thanks.
What about
current or past prescribed medications, and their effects? Any past
hospitalizations for this or other diseases? Do you
suffer from other internal diseases? If you do, please describe the degree
of seriousness.
Do you wish to come to
China to our hospital for better help? Let us know the approximate date
of arrival, the approximate period of time to stay here. Please seek an
official invitation letter from us now so that you could get a three
months visa for you and your accompanying persons.
If you are not able to be here, commonly
there are four ways that we could
help you.
The first choice is
the prepared herbal products produced by hundreds different herbal
companies in China. We have four hundreds different perfect herbal
products for various commonly encountered diseases.
Check Here.
The second choice
is raw herb tea. We could prescribe a special herbal formula for you, then mix
the raw herbs. Please decoct the raw herbs to make
herbal tea, drink the tea twice a day. The adult dosage is 200 milliliters
each time. The first treatment course will be 20 days. We will air ship to you. The general
cost for 20 days supply will be US$160.00 for you.
The third choice is
herbal granule. We could prescribe a special herbal formula for you.
The herbal granule is dissoluble and
concentrated made through modern technology. Each dosage is composed of
different sachets of granule. Please cut every sachet and put the
granule into a cup. Put a little hot water into the cup and stir the
herbal granule. For adult, after that please put another 250ml boiling
water into the cup and stir it with spoon. You will get some liquid,
drink it when it is cool or still warm. Please drink half of the liquid
in the morning and another half of that in the afternoon.
The general cost for
20 days will be US$140.00 for you.
The fourth choice is
honey herb pills. We could make the herbal powder into honey herb candies for you. You could first
order 20 days supply as the first treatment course. It is about 200
pills
for you, about 10 grams each pill. The adult dosage is 3 to 4 pills each time, three times a day. We will air ship the
package to
you. The general cost for 20 days will be US$140.00 for you.
Please let us know
what choice you prefer.
Before submitting
your form, please check if you
have correctly filled out your email address. Thanks.
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